BMJ Case Reports

We report on a patient with coronavirus disease 2019 (COVID-19) and decompensated cirrhosis who experienced a favourable outcome of severe immune thrombocytopaenic purpura (ITP) after administration of intravenous immunoglobulin and high-dose dexamethasone. The present case suggests that it is reasonable to evoke ITP in case of profound thrombocytopaenia in a patient with COVID-19.

Avulsion fracture of coracoid process with acromioclavicular joint dislocation is extremely rare. We report a case of coracoid avulsion with acromioclavicular disruption in a 24-year-old man who sustained injuries in a road traffic accident. Although acromioclavicular (AC) dislocation was obvious from an initial radiograph, coracoid avulsion was picked up in a CT scan. Open reduction and internal fixations of the coracoid with a 4 mm cannulated screw, an AC joint with two K-wires and an anchor suture, resulted in rapid recovery. The patient had complete range of shoulder movements at the end of 3 months and he resumed his professional activities. After 1 year, he had normal shoulder movement without any functional limitations.

A 23-year-old man with poorly controlled insulin-dependent diabetes mellitus presented to casualty with community-acquired pneumonia and diabetic ketoacidosis. Shortly after admission he deteriorated and developed cardiac failure, pulmonary oedema and further decreased level of consciousness. He was sedated and ventilated for 3 weeks in the intensive care unit. On waking from sedation he was found to be tetraplegic. MRI scan showed gross oedema of the cervical spinal cord with area suspicious of infarction. We describe a rare cause of spinal cord injury and discuss the proposed hypotheses.

COVID-19 is caused by the novel SARS-CoV-2 and is a potentially fatal disease that is of great global public health concern. In addition to respiratory symptoms, neurological manifestations have been associated with COVID-19. This is attributed to the neurotropic nature of coronaviruses. The authors present a case of Bell’s palsy associated with COVID-19 in a term primigravida.

An 85-year-old man was referred to endocrinology following the discovery of an incidental pituitary mass on cranial imaging which was thought to be a non-functioning adenoma during an admission with headaches, lethargy, confusion and hyponatraemia. He had a history of Hürthle cell carcinoma of the thyroid treated with total thyroidectomy, ablative radioiodine therapy and thyroxine replacement. Subsequently, he developed metastatic spread to the neck, lungs and skeleton. About 9 months later, the patient had deterioration of vision. MRI showed a rapidly expanding pituitary mass with compression of the optic chiasm. Biochemical investigations confirmed hypocortisolism and hypogonadism. The patient underwent trans-sphenoidal resection of the pituitary mass followed by external beam radiotherapy to the pituitary bed. Histopathology confirmed a metastatic deposit of Hürthle cell carcinoma, which is a rare and aggressive variant of follicular thyroid carcinoma.

Krabbe disease is a rare autosomal recessive leucodystrophy, with <5% of the cases having an adolescent-onset form. A 30-year-old woman with a history of a subacute episode of gait impairment at 14 years of age, and mild spastic paraparesis since then, was followed with an initial diagnosis of multiple sclerosis. After 10 years of slow disease progression without response to treatment, the initial diagnosis was reviewed, and an extensive metabolic work up revealed decreased activity of galactocerebrosidase. Genetic testing of the GALC gene proved the diagnosis of Krabbe disease and found a novel mutation. This case highlights the value of a critical eye in the initial differential diagnosis, mainly in the presence of atypical findings.

Acute colonic pseudo-obstruction (ACPO), or Ogilvie’s syndrome, is a rare clinical entity in which there is massive non-toxic colonic dilatation in the absence of a mechanically obstructing lesion. It is an important yet poorly recognised cause of surgical morbidity and mortality occurring typically in elderly patients with multiple comorbidities. ACPO can often be reversed conservatively with colonoscopic or nasogastric decompression. Surgical intervention is seldom necessary. We present a case of Ogilvie’s syndrome in which a healthy 76-year-old man developed life-threatening pseudo-obstruction following rib polytrauma after a mechanical fall. Pneumatosis coli was evident radiologically, prompting emergency exploratory laparotomy. Operative findings of serosal tearing and ischaemic colitis necessitated treatment with right hemicolectomy and ileostomy formation. Microbiological and histopathological analyses proved negative for inflammatory, obstructive and infectious colitides. The case emphasises the importance of early recognition and timely intervention in the management of this rare yet potentially fatal cause of megacolon.